Surgical Issues for Operable Early-Stage Non-Small-Cell Lung Cancer.

Surgical care for early stage non-small-cell lung cancer continuously evolves with new procedures, techniques and care pathways. The most obvious recent change was the transition to minimally invasive procedures, but numerous other aspects of care have also been refined to improve safety and tolerability. These care advancements are essential as we move into an era with increased early detection as a result of screening and greater indications for the use of adjuvant and neoadjuvant strategies.

VATS lobectomy morbidity and mortality is lower in patients with the same ppoDLCO: Analysis of the database of the Spanish Video-Assisted Thoracic Surgery Group / La lobectomía VATS tiene una menor morbimortalidad para una misma ppoDLCO: análisis de base de datos del Grupo Español de Cirugía Torácica Video-asistida

Introduction: Measuring predicted post-operative diffusion capacity of the lung for carbon monoxide (ppoDLCO) is essential to determine patient operability and to stratify the risk of patients who are candidates for major lung cancer surgery. Studies that established surgical risk variables were based on open surgery series. The aim of our study was to analyze morbidity and mortality as a function of ppoDLCO and to compare its behavior in open and video-assisted thoracic surgery (VATS). Methods: We compared 90-day mortality and morbidity in patients undergoing open surgery versus VATS as a function of decline in ppoDLCO. Propensity score matching (using age, ASA, arterial vascular disease, BMI, gender, stage, ppoDLCO, and ppoFEV1) was applied to create comparable open surgery and VATS groups. Results: Of 2,530 patients with lung cancer and ppoDLCO values, a sample of 1,624 (812 per group) was obtained after score matching. The relative risk of mortality associated with thoracotomy in patients with ppoDLCO < 60 is 2.66 (p < 0.02) compared to VATS. The risk of thoracotomy in terms of overall and cardiac and respiratory morbidity is higher than that of VATS for almost all ppoDLCO values. Conclusions: Major resection by VATS shows lower morbidity and mortality in patients with the same ppoDLCO. A steady rise in the risk of mortality begins to occur at higher ppoDLCO values in thoracotomy (∼60) than in VATS (∼45). (AU)

Introducción: La medición de la capacidad de difusión del carbono monóxido postoperatoro (ppoDLCO) es esencial para la operabilidad del paciente y la estratificación del riesgo de los pacientes subsidiarios de una resección pulmonar mayor por cáncer. Los estudios que fijan los límites de riesgo quirúrgico se basan en series de cirugía abierta. El objetivo de nuestro trabajo es analizar la morbilidad y mortalidad en relación a la ppoDLCO y comparar su comportamiento en cirugía abierta y cirugía torácica videoasistida (VATS). Métodos: Comparación de la mortalidad a 90 días y la morbilidad en pacientes intervenidos por cirugía abierta frente a videoasistida en relación al descenso de la ppoDLCO. Emparejamiento por puntaje de propensión (variables: edad, ASA, vasculopatía arterial, IMC, sexo, estadio, ppoDLCO y ppoFEV1) para realizar grupos comparables entre abierta y VATS. Resultados: De 2.530 pacientes con cáncer de pulmón y medición de ppoDLCO, se obtiene tras el pareamiento por puntaje una muestra de 1.624 (812 por grupo). El riesgo relativo de mortalidad de la toracotomía para una ppoDLCO <60 es de 2,66 (p < 0,02) respecto a la videocirugía. Tanto para morbilidad total como para la cardíaca y respiratoria, el riesgo de la toracotomía es superior a la videocirugía para casi todos los valores de ppoDLCO. Conclusiones: La resección mayor por VATS muestra una morbimortalidad inferior para una misma ppoDLCO. El aumento continuo del riesgo de mortalidad empieza a darse en valores de ppoDLCO superiores en toracotomía (∼60) que en VATS (∼45). (AU)

Characterization of Outcomes by Surgical Management of Lung Neuroendocrine Tumors Associated With Cushing Syndrome.

Importance: Ectopic adrenocorticotropic hormone secretion from lung tumors causing Cushing syndrome are associated with high rates of morbidity. Optimal management remains obscure because knowledge is based on rare reports with few patients. Objective: To characterize the outcomes of lung neuroendocrine tumors associated with Cushing syndrome. Design, Setting, and Participants: An observational case series review from 1982 to 2020 was conducted in a single institution referral center. Kaplan-Meier analysis estimated disease-free survival (DFS). Participants underwent curative-intent surgery for a lung neuroendocrine tumor causing Cushing syndrome. Exposures: Lobectomy or pneumonectomy vs sublobar resection. Main Outcomes and Measures: Disease-free survival, disease persistence/recurrence. Results: Of the 68 patients, the median age was 41 years (range, 17-80 years), 42.6% (29 of 68) were male, 81.8% (54 of 66) were White, with a mean follow-up after surgery was 16 months (range, 0.1-341 months). Lobectomy was the most common procedure (48 of 68 [70.6%]), followed by wedge resection (16 of 68 [23.5%]) and segmentectomy (3 of 68 [4.4%]). Video-assisted thoracoscopic surgery was performed in 19 of 68 (27.9%) of patients. Surgical morbidity was 19.1% (13 of 68), and perioperative mortality was 1.5% (1 of 68). Lymph node positivity was 37% (22 of 59) when evaluable. The overall incidence of persistence/recurrence was 16.2% (11 of 68) with a median time to recurrence of 55 months (range, 18-152 months). The median DFS was reached in 12.7 years (0.1-334 months). There were no statistical differences in DFS based on tumor size, stage (8th edition TNM), whether full systematic lymphadenectomy was performed or not, nodal status, or surgical approach. Conclusions and Relevance: In this case series study, neuroendocrine pulmonary tumors associated with Cushing syndrome had increased nodal metastasis, higher recurrence, and lower DFS than quiescent bronchopulmonary carcinoid tumors, but many patients experienced favorable outcomes. This observation is underscored by the discordance of TNM-stage classifications vs prognosis. Observing no difference in surgical techniques, the implication may be that a lung-sparing approach could suffice. These results may reflect the intrinsic importance of the hormone physiology instead of the carcinoid biologic factors.

Stereotactic ablative radiotherapy for operable stage I non-small-cell lung cancer (revised STARS): long-term results of a single-arm, prospective trial with prespecified comparison to surgery.

BACKGROUND: A previous pooled analysis of the STARS and ROSEL trials showed higher survival after stereotactic ablative radiotherapy (SABR) than with surgery for operable early-stage non-small-cell lung cancer (NSCLC), but that analysis had notable limitations. This study reports long-term results of the revised STARS trial, in which the SABR group was re-accrued with a larger sample size, along with a protocol-specified propensity-matched comparison with a prospectively registered, contemporary institutional cohort of patients who underwent video-assisted thoracoscopic surgical lobectomy with mediastinal lymph node dissection (VATS L-MLND). METHODS: This single-arm prospective trial was done at the University of Texas MD Anderson Cancer Center (Houston, TX, USA) and enrolled patients aged 18 years or older with a Zubrod performance status of 0-2, newly diagnosed and histologically confirmed NSCLC with N0M0 disease (squamous cell, adenocarcinoma, large cell, or NSCLC not otherwise specified), and a tumour diameter of 3 cm or less. This trial did not include patients from the previous pooled analysis. SABR dosing was 54 Gy in three fractions (for peripheral lesions) or 50 Gy in four fractions (for central tumours; simultaneous integrated boost to gross tumour totalling 60 Gy). The primary endpoint was the 3-year overall survival. For the propensity-matching analysis, we used a surgical cohort from the MD Anderson Department of Thoracic and Cardiovascular Surgery's prospectively registered, institutional review board-approved database of all patients with clinical stage I NSCLC who underwent VATS L-MLND during the period of enrolment in this trial. Non-inferiority could be claimed if the 3-year overall survival rate after SABR was lower than that after VATS L-MLND by 12% or less and the upper bound of the 95% CI of the hazard ratio (HR) was less than 1·965. Propensity matching consisted of determining a propensity score using a multivariable logistic regression model including several covariates (age, tumour size, histology, performance status, and the interaction of age and sex); based on the propensity scores, one patient in the SABR group was randomly matched with one patient in the VATS L-MLND group using a 5:1 digit greedy match algorithm. This study is registered with ClinicalTrials.gov, NCT02357992. FINDINGS: Between Sept 1, 2015, and Jan 31, 2017, 80 patients were enrolled and included in efficacy and safety analyses. Median follow-up time was 5·1 years (IQR 3·9-5·8). Overall survival was 91% (95% CI 85-98) at 3 years and 87% (79-95) at 5 years. SABR was tolerated well, with no grade 4-5 toxicity and one (1%) case each of grade 3 dyspnoea, grade 2 pneumonitis, and grade 2 lung fibrosis. No serious adverse events were recorded. Overall survival in the propensity-matched VATS L-MLND cohort was 91% (95% CI 85-98) at 3 years and 84% (76-93) at 5 years. Non-inferiority was claimed since the 3-year overall survival after SABR was not lower than that observed in the VATS L-MLND group. There was no significant difference in overall survival between the two patient cohorts (hazard ratio 0·86 [95% CI 0·45-1·65], p=0·65) from a multivariable analysis. INTERPRETATION: Long-term survival after SABR is non-inferior to VATS L-MLND for operable stage IA NSCLC. SABR remains promising for such cases but multidisciplinary management is strongly recommended. FUNDING: Varian Medical Systems and US National Cancer Institute (National Institutes of Health).

Video-assisted pulmonary metastectomy is equivalent to thoracotomy regarding resection status and survival.

BACKGROUND: Surgical resection of pulmonary metastases leads to prolonged survival if strictly indicated. Usually, thoracotomy with manual palpation of the entire lung with lymph node dissection or sampling is performed. The aim of this study was to evaluate the role of video-assisted thoracoscopic surgery (VATS) in pulmonary metastectomy with curative intent. METHODS: In this study, all patients with suspected pulmonary metastasis (n = 483) who visited the Center for Thoracic Surgery in Regensburg, between January 2009 and December 2017 were analysed retrospectively. RESULTS: A total of 251 patients underwent metastectomy with curative intent. VATS was performed in 63 (25.1%) patients, 54 (85.7%) of whom had a solitary metastasis. Wedge resection was the most performed procedure in patients treated with VATS (82.5%, n = 52) and thoracotomy (72.3%, n = 136). Postoperative revisions were necessary in nine patients (4.8%), and one patient died of pulmonary embolism after thoracotomy (0.5%). Patients were discharged significantly faster after VATS than after thoracotomy (p < 0.001). Complete (R0) resection was achieved in 89% of patients. The median recurrence-free survival was 11 months (95% confidence interval 7.9-14.1). During follow-up, eight (12.7%) patients in the VATS group and 42 (22.3%) patients in the thoracotomy group experienced recurrence (p = 0.98). The median overall survival was 61 months (95% confidence interval 46.1-75.9), and there was no significant difference with regard to the surgical method used (p = 0.34). CONCLUSIONS: VATS metastasectomy can be considered in patients with a solitary lung metastasis. An open surgical approach with palpation of the lung showed no advantage in terms of surgical outcome or survival.

Outcomes after Contralateral Anatomic Surgical Resection in Multiple Lung Cancer.

BACKGROUND: Patients treated surgically for lung cancer may present synchronous or metachronous lung cancers. The aim of this study was to evaluate outcomes after a second contralateral anatomic surgical resection for lung cancer. METHODS: We performed a retrospective two-center study, based on a prospective indexed database. Included patients were treated surgically by bilateral anatomic surgical resection for a second primary lung cancer. We excluded nonanatomic resections, benign lesions, and ipsilateral second surgical resections. RESULTS: Between January 2011 and September 2018, 55 patients underwent contralateral anatomic surgical resections for lung cancer, mostly for metachronous cancers. The first surgical resection was a lobectomy in most cases (45 lobectomies: 81.8%, 9 segmentectomies: 16.4%, and 1 bilobectomy: 1.8%), and a video-assisted thoracic surgery (VATS) procedure was used in 23 cases (41.8%). The mean interval between the operations was 38 months, and lobectomy was less frequent for the second surgical resection (35 lobectomies: 63.6% and 20 segmentectomies: 36.4%), with VATS procedures performed in 41 cases (74.5%). Ninety-day mortality was 10.9% (n = 6), and 3-year survival was 77%. Risk factor analysis identified the number of resected segments during the second intervention or the total number of resected segments, extent of resection (lobectomy vs. segmentectomy), surgical approach (thoracotomy vs. VATS), tumor stage, and nodal involvement as potential prognostic factors for long-term survival. CONCLUSION: A second contralateral anatomic surgical resection for multiple primary lung cancer is possible, with a higher early mortality rate, but acceptable long-term survival, and should be indicated for carefully selected patients.

Comparison of video-assisted thoracoscopic surgery with thoracotomy in bronchial sleeve lobectomy for centrally located non-small cell lung cancer.

OBJECTIVES: The aim of this study was to investigate the adequacy of bronchial sleeve lobectomy by video-assisted thoracoscopic surgery in perioperative outcomes and its oncological efficacy by comparing with thoracotomy in a balanced population. METHODS: A total of 363 patients who received bronchial sleeve lobectomy for non-small cell lung cancer from January 2013 to December 2017 were included and placed in the thoracotomy (n = 251) and video-assisted thoracoscopic surgery (n = 112) groups. Statistical analyses were performed to compare patients' demographics, perioperative outcomes, and survival between the 2 groups. RESULTS: A total of 116 thoracotomy cases were matched with 72 video-assisted thoracoscopic surgery cases by propensity score. Compared with thoracotomy, patients in the video-assisted thoracoscopic surgery group after matching had less intraoperative blood loss (P < .01) and length of postoperative hospital stay (P < .01), duration of chest tube drainage (P < .01), and intensive care unit stay (P = .03) despite comparable operative time, complication rate, and 30- to 90-day mortality rate. The overall survival and recurrence-free survival were similar in patients who received sleeve lobectomy by thoracotomy and video-assisted thoracoscopic surgery (log-rank, P = .24 and .20, respectively) at 3 years. Although advanced TNM stage was independently associated with worse overall survival and recurrence-free survival in multivariable analysis, older age was only predictive for worse overall survival (hazard ratio, 1.04; 95% confidence interval, 1.01-1.07; P = .02). Body mass index was also found be a predictive factor (overall survival: hazard ratio, 0.93; 95% confidence interval, 0.86-0.99, P = .03; recurrence-free survival: hazard ratio, 0.93; 95% confidence interval, 0.87-0.99, P = .02). CONCLUSIONS: With appropriate patient selection and continued experience, video-assisted thoracoscopic surgery appears to be safe in the short-term perioperative period and does not appear to comprise oncologic outcomes in performing sleeve lobectomy.

Results of video-assisted thoracic surgery versus thoracotomy in surgical resection of pN2 non-small cell lung cancer in a Chinese high-volume Center.

PURPOSE: To investigate the short-term outcomes and long-term oncological efficacy of video-assisted thoracic surgery (VATS) for surgical treatment of pN2 non-small cell lung cancer (NSCLC) compared with open thoracotomy (OT). PATIENTS AND METHODS: We retrospectively collected data from 1034 patients who underwent pulmonary resection and systemic lymph node dissection for pathological N2 NSCLC from September 2005 to December 2017 (536 patients in VATS group and 498 patients in OT group). Propensity score matching was applied to reduce the confounding effects. Factors affecting survival were assessed by Kaplan-Meier estimates and Cox regression analysis. RESULTS: The VATS procedure was associated with shorter operative time compared with the OT procedure (147.96 ± 58.91 min vs. 165.34 ± 58.91 min, P < 0.001). No significant difference was identified between the two groups in the number of dissected mediastinal lymph nodes (MLNs) and number of dissected MLNs stations. More patients after VATS procedure received postoperative adjuvant therapy (83.4% vs. 75.5%, P = 0.002). At a median follow-up of 36 (range 4-150) months, comparing VATS procedure and OT procedure, no significant differences were noted in 5-year DFS (20.7% vs. 22.5%, P = 0.89) and 5-year OS (30.7% vs. 34.5%, P = 0.821). The VATS procedure was not found to be an independent predictor of DFS (hazard ratio, 0.986; 95% CI, 0.809 to 1.202) or OS (hazard ratio, 0.977; 95% CI 0.802 to 1.191). CONCLUSION: In this large propensity-matched comparison, the VATS procedure offered comparable short-term outcomes and long-term oncological efficacy for patients with pN2 NSCLC when compared with OT procedure.

Comparison of Subxiphoid and Intercostal Uniportal Thoracoscopic Thymectomy for Nonmyasthenic Early-Stage Thymoma: A Retrospective Single-Center Propensity-Score Matching Analysis.

OBJECTIVE: The aim of this study was to compare early outcome between intercostal uniportal video-assisted thoracoscopic surgery (IU-VATS) versus subxiphoid uniportal video-assisted thoracoscopic surgery (SU-VATS) in thymectomy for non-myasthenic early-stage thymoma. METHOD: Retrospective analysis of 76 cases completed in our hospital from May 2018 to September 2019 with subxiphoid uniportal thoracoscopic thymectomy; a single incision of ∼3 cm was made ∼1 cm under the xiphoid process. The control group included 213 patients who received intercostal uniportal thoracoscopic thymectomy from August 2015, and propensity score matching was conducted. All patients who were clinically diagnosed with thymic tumor before surgery were treated with thymectomy. Perioperative outcomes between SU-VATS (n = 76) and IU-VATS, n = 76 were compared. RESULT: After propensity score matching, there were no statistically significant differences between the two groups in terms of age, gender, disease stage, maximal tumor size, or other baseline demographic and clinical variables. All operation was successfully completed; there were no significant differences in the operative time (88 vs. 81 minutes, p = 0.63), intraoperative blood loss (55 vs. 46 mL, p = 0.47), postoperative drainage time (2.2 vs. 2.5 days, p = 0.72), and postoperative hospital stay (3.2 vs. 3.4 days, p = 0.78) between the two groups. The visual analog scale (VAS) on postoperative days 1, 3, 7, and 30 was less in the SU-VATS group than that in the IU-VATS group. The VAS on days 60 and 180 did not differ significantly between the two groups. CONCLUSION: Thymectomy using SU-VATS is a feasible procedure; it might reduce early postoperative pain and lead to faster recovery.

Evaluating Giant Hydatid Cysts: Factors Affecting Mortality and Morbidity.

OBJECTIVE: The aim of this study was to evaluate the prognostic factors affecting morbidity and mortality among patients who underwent surgery for giant pulmonary hydatid cysts in our center. METHODS: Data from 283 patients who underwent surgery in our center for pulmonary hydatid cyst between 2008 and 2018 were retrospectively analyzed. Cysts 10 cm in diameter or larger were considered giant hydatid cysts. RESULTS: There were 145 women (51.2%) and 138 men (48.8%). Giant cyst (≥10 cm) was present in 57 patients (20.1%), while the other 226 patients (79.9%) had cysts smaller than 10 cm. Operations were performed using videothoracoscopic approach in 68 patients (24%) and with thoracotomy in 215 patients (76%). Hydatid cysts were on the left side in 129 patients (45.6%), on the right side in 143 patients (50.5%), and bilateral in 11 patients (3.9%). Postoperative morbidity occurred in 29 patients (10.2%). Use of videothoracoscopic surgical approach did not affect morbidity. The mortality rate within the first 90 days was 0.35% (n = 1). CONCLUSION: Giant cysts are more common in the young age group than in older adults. Regardless of cyst size, surgery should be performed as soon as possible after diagnosis to avoid potential complications.

Video-assisted thoracoscopic pneumonectomy for destroyed lung.

AIM: Destroyed lung refers to destruction of a large portion of a lung induced by chronic or recurrent lung infections. The aim of this single-center retrospective review was to evaluate patients with a diagnosis of destroyed lung undergoing pneumonectomy via video-assisted thoracoscopic surgery, in terms of surgical technique, postoperative morbidity and mortality, and long-term outcomes. METHODS: Data of 15 patients who underwent video-assisted thoracoscopic pneumonectomy for destroyed lung during a 4-year period were analyzed retrospectively. There were 9 (60%) males and 6 (40%) females with a median age of 33.87 years (range 8-52 years). Bronchiectasis (n = 7), tuberculosis (n = 5), and fungal infection (n = 3) were the main etiologies. Hemoptysis was the most common presenting symptom (n = 8, 53.3%). Destroyed lung was detected on the left side in 13 (86.7%) patients and on the right side in 2 (13.3%). Seven patients showed narrowing or thickening of the main bronchus. RESULTS: Video-assisted thoracoscopic pneumonectomy was attempted in all patients but 5 (33.3%) were converted to a thoracotomy. The mean operative time was 273.8 min. The postoperative morbidity rate was 13.3%. The mortality rate was 6.67%. The median length of hospital stay was 3.5 days. The mean follow-up period was 23.7 months. Significant improvement was observed in inflammatory symptoms and quality of life in all patients. The overall 1-year survival was 93.3%. CONCLUSION: Video-assisted thoracoscopic pneumonectomy for destroyed lung is a safe and feasible option in selected patients, which can be used as an alternative to thoracotomy.

Operative invasiveness does not affect the prognosis of patients with non-small cell lung cancer.

BACKGROUND: The relationship between operative invasiveness and the prognosis in non-small cell lung cancer (NSCLC) patients who have undergone surgery has been controversial. METHODS: Clinical data were analyzed for 463 NSCLC patients. Operative invasiveness was defined by wound length, operation time, and the postoperative C-reactive protein (postCRP) level. The operative approach was divided into video-assisted thoracic surgery (VATS) and thoracotomy. RESULTS: The wound length and operation time were significantly correlated with the postCRP level (correlation coefficient (CC) = 0.39, p <  0.01; CC = 0.54, p <  0.01, respectively). The postCRP level in the VATS group was significantly lower than that in the thoracotomy group (12.2 mg/dl vs 20.58 mg/dl, p <  0.01). The relapse-free survival differed significantly based on wound length (p <  0.01), operation time (p = 0.01), CRP level (p <  0.01), and operative approach (p <  0.01). The carcinoembryonic antigen level (hazard ratio [HR], 1.58; p = 0.02), pathological stage (pStage) (HR, 2.57; p <  0.01), vascular invasion (HR, 1.95; p = 0.01), and preoperative CRP level (preCRP) (HR, 1.91; p <  0.01) were identified as significant prognostic factors for relapse-free survival in a multivariate analysis. Furthermore, the multivariate analysis showed that smoking history (HR, 2.36; p = 0.03), pStage (HR, 3.26; p <  0.01), and preCRP level were significant prognostic factors for overall survival. CONCLUSION: Preoperative CRP level was associated with poor prognosis. Although the VATS approach might be less invasive procedure for NSCLC patients, operative invasiveness does not affect the prognosis.

Comparison of Surgical Stabilization Time in Patients with Flail Chest.

BACKGROUND: This study aimed to compare the clinical outcomes of early and late surgical stabilization of rib fractures (SSRFs) in patients with flail chest. METHODS: A retrospective analysis was performed on patients with flail chest according to surgical stabilization time of rib fractures (early [≤ 72 hours] and late [>72 hours]). Outcome measures included duration of mechanical ventilation, intensive care unit (ICU) stay, hospital stay, and morbidity and mortality rates. A correlation analysis was performed between the time from trauma to stabilization and the clinical outcomes after stabilization. RESULTS: A total of 70 patients were evaluated (36 and 34 in the early and late groups, respectively). The demographics and indicators of injury severity were comparable in both groups. The early group had significantly shorter duration of mechanical ventilation (23.7 vs. 165.6 hours; p = 0.003), ICU stay (6.5 vs. 19.7 days; p = 0.003), hospital stay (9 vs. 22.5 days; p = 0.001), and lower rate of atelectasis (11 vs. 58%; p = 0.01), pneumonia (8.8 vs. 50%; p = 0.001), and empyema (2.8 vs. 20.6%; p = 0.019). According to the correlation analysis, it was found that early surgical stabilization had a positive significant effect on clinical outcomes after stabilization. CONCLUSION: Early SSRFs in patients with flail chest results in more favorable clinical outcomes. It should be performed as soon as possible in the presence of indication and if feasible.

[Short-term results of video-assisted lung cancer surgery in octogenarians]. / Morbi-mortalité de la résection pulmonaire pour cancer par chirurgie vidéo-assistée chez l'octogénaire.

INTRODUCTION: Due to an increase in life expectancy, onco-pulmonologists and thoracic surgeons are more frequently faced with octogenarian patients with lung cancer. In this age group, treatment modalities may need to be revised because of the increasing presence of comorbidities. Surgery remains the reference treatment for early stage disease, but mortality rates and postoperative complications are higher in this group of patients. One of the solutions to reduce the operative risk would be to develop videoassisted thoracoscopic pulmonary resection surgery. The aim of this study was to evaluate the results of this form of lung cancer surgery in octogenarians. METHODS: All patients 80 years old or more who underwent videoassisted lung cancer surgery from 2014 to 2018 at Lyon University Hospital were included. Wedge resections and diagnostic procedures were excluded. RESULTS: Nineteen patients (13 men, 6 women) were included. The median age was 82 years old. All patients had undergone videoassisted lobectomy. Three patients required conversion to thoracotomy (15.8%). All patients underwent complete resection (R0). One patient had N1 lymph node involvement, all others were N0. The postoperative complication rate was 68.4%, the majority of which were grade II of the Clavien classification. Perioperative mortality was 5.3%. CONCLUSIONS: Videoassisted lung cancer resection in a selected population of octogenarians is associated with satisfactory short-term results. It is reasonable to favour minimally invasive techniques in this population, even if the proof of their superiority has not yet been firmly established.

A national analysis of open versus minimally invasive thymectomy for stage I to III thymoma.

OBJECTIVE: The oncologic efficacy of minimally invasive thymectomy for thymoma is not well characterized. We compared short-term outcomes and overall survival between open and minimally invasive (video-assisted thoracoscopic and robotic) approaches using the National Cancer Data Base. METHODS: Perioperative outcomes and survival of patients who underwent open versus minimally invasive thymectomy for clinical stage I to III thymoma from 2010 to 2014 in the National Cancer Data Base were evaluated using multivariable Cox proportional hazards modeling and propensity score-matched analysis. Predictors of minimally invasive use were evaluated using multivariable logistic regression. Outcomes of surgical approach were evaluated using an intent-to-treat analysis. RESULTS: Of the 1223 thymectomies that were evaluated, 317 (26%) were performed minimally invasively (141 video-assisted thoracoscopic and 176 robotic). The minimally invasive group had a shorter median length of stay when compared with the open group (3 [2-4] days vs 4 [3-6] days, P < .001). In a propensity score-matched analysis of 185 open and 185 minimally invasive (video-assisted thoracoscopic + robotic) thymectomy, the minimally invasive group continued to have a shorter median length of stay (3 vs 4 days, P < .01) but did not have significant differences in margin positivity (P = .84), 30-day readmission (P = .28), 30-day mortality (P = .60), and 5-year survival (89.4% vs 81.6%, P = .20) when compared with the open group. CONCLUSIONS: In this national analysis, minimally invasive thymectomy was associated with shorter length of stay and was not associated with increased margin positivity, perioperative mortality, 30-day readmission rate, or reduced overall survival when compared with open thymectomy.

Surgical effect and prognostic factors of myasthenia gravis with thymomas.

BACKGROUND: To evaluate the surgical effect and prognostic factors of extended thymectomy for myasthenia gravis (MG) patients with thymomas. METHODS: Patients with MG with thymomas who underwent extended thymectomy at Peking University People's Hospital and Beijing Hospital between January 2010 and December 2018 were retrospectively enrolled. Patients were followed up by telephone or outpatient record review . Statistical analyses were performed using SPSS version 19.0. RESULTS: A total of 194 patients were included in this study. According to the Osserman classification, there were 56 type I, 52 type IIa, 67 type IIb, 14 type III, and five type IV. Video-assisted thoracoscopic surgery (VATS) thymectomies were performed in 137 patients, and transthymectomies in 57 patients. The average operation time was 136.6 ± 46.5 minutes, average blood loss was 129.3 ± 287.4 mL, and average postoperative stay was 8.3 ± 7.4 days. A total of 170 patients (87.6%) were successfully followed up. The median follow-up period was 45 months, and the five-year overall survival (OS) rate was 81.9%. Cox regression analysis demonstrated that age, Masaoka stage, and recurrence were prognostic factors of OS. Tumor recurrence tended to occur in patients with Masaoka stage III + IV, and age was a protective factor. A total of 20 patients experienced postoperative myasthenic crisis (POMC). Univariate analysis indicated that presence of bulbar symptoms, surgical procedure, and blood loss were risk factors for POMC, but multivariate analysis only indicated the presence of bulbar symptoms as an independent risk factor. A total of 162 patients were evaluated for post intervention MG status. A total of 55 patients achieved complete stable remission; the overall effective rate was 84.5%. Older patients and those with B-type thymomas had a lower probability of achieving complete stable remission. Efficacy was similar in patients who underwent VATS or the transsternal procedure. CONCLUSIONS: Age, Masaoka stage, and recurrence were prognostic factors of OS. Presence of bulbar symptoms was an independent risk factor for POMC. Age and World Health Organization classification influence the postoperative effect of MG. KEY POINTS: Significant findings of the study Age, Masaoka stage, and recurrence were prognostic factors of OS for MG with thymomas. The presence of bulbar symptoms was an independent risk factor for POMC. Age and World Health Organization classification may influence the postoperative effect of MG. What this study adds Our study had a relatively large sample size of MG patients with thymomas only. We emphasize the analysis of the postoperative effect of MG and overall survival for these patients, which is a complement to previous studies.

A survey of one-lung ventilation device in lung resection surgeries in Taiwan-A population-based nationwide cohort study.

BACKGROUND: Double-lumen endotracheal tubes and bronchial blockers are the two lung separation devices most commonly used for lung resection. The preference and outcomes of choosing different lung separation devices have not been discussed in the literature. METHODS: This study was conducted using the data of 2 million patients randomly chosen from the National Health Insurance Research Database between 2011 and 2016. We selected patients who underwent lung resection surgery and surveyed their demographic data and trends of double-lumen endotracheal tube and bronchial blocker use. To determine the influence of endotracheal tubes on clinical outcomes, we computed multiple linear regressions of the number of deaths within 30 days after surgery, intensive care unit stay, hospital stay, and medical cost. RESULTS: The use of bronchial blockers in Taiwan has steadily increased from 6.13% to 11.33% from 2011 to 2016. Anaesthesiologists working in regions with higher thoracic surgery volumes preferred bronchial blockers over double-lumen endotracheal tubes. Bronchial blockers were the preferred choice in women, elderly individuals, patients with more comorbidities, and those undergoing video-assisted thoracoscopic surgeries. After adjustment for sex, age, Charlson Comorbidity Index, and video-assisted thoracoscopic surgeries, we found that patients in whom bronchial blockers were applied had shorter hospital stays. CONCLUSION: The use of bronchial blockers is increasing as the experience of anaesthesiologists increases. Although double-lumen endotracheal tubes remain the principal choice for lung separation in Taiwan, clinical outcomes of the bronchial blocker group were not inferior to those of the double-lumen endotracheal tube group.

Video-assisted thoracoscopic surgery for thoracic empyema in patients on maintenance hemodialysis.

OBJECTIVE: Thoracic empyema in uremic patients on maintenance hemodialysis is a challenging situation. The clinical characteristics are rarely reported, and the surgical outcomes remain unclear. We report our experience with video-assisted thoracoscopic surgery in these patients during 10-year period of time. METHODS: Between 2005 and 2015, we retrospectively reviewed the clinical characteristics, bacteriological studies, and thoracoscopic surgical results of 23 empyema patients undergoing maintenance hemodialysis. RESULTS: The mean patient age was 67.1 ± 12.9 years. All patients had additional preexisting systemic diseases. The mean duration of hemodialysis was 34.7 ± 25.8 months. The infections causing empyema were pneumonia in 11 (47.8%), blood stream infection in 8 (34.8%), and uremic pleuritis in 4 (17.4%). Among the 22 identified microorganisms, the most common pathogen was methicillin-resistant Staphylococcus aureus (31.8%). After thoracoscopic surgery, 8 patients (34.8%) required additional procedures for complications, including 2 patients who required repeated thoracoscopy for hemothorax and 6 (26.1%) patients who required open drainage for residual empyema. The mean hospital stay was 62.4 days, and 6 patients (26.1%) died in the hospital. Univariate and multivariate analyses revealed that maintenance hemodialysis longer than 5 years was a significant factor associated with in-hospital mortality (odds ratio: 14.8, 95% confidence interval 1.5-151.6; p < 0.0001). CONCLUSION: While surgical management of thoracic empyema in uremic patients undergoing maintenance hemodialysis is associated with high rates of complication and mortality, thoracoscopic surgery is feasible, especially for patients undergoing hemodialysis for less than 5 years.

Retrospective Observational Study into the Early Causes of Death Following Surgery for NSCLC.

INTRODUCTION: Respiratory failure has historically been the major cause of mortality after elective lung resections. With improved intubation using fiber-optic scopes, better preoperative respiratory risk assessment, more advanced anesthetic single lung ventilation, and minimally invasive surgical technique, this may have changed. Our objective was to assess the main causes of mortality over the past 10 years in patients undergoing elective lung surgery in a major UK center. MATERIALS AND METHODS: A retrospective unit data search was made for all deaths during the 10-year period between January 2007 and December 2016 inclusive. All inpatient deaths within 30 days of an elective anatomical lung resection for lung malignancies were included. RESULTS: Three-thousand three-hundred sixteen lung resections for malignancy were performed in the 10-year period. There were 44 (1.3%) deaths during this period, 27 (61.4%) after open lobectomies, 8 (18.2%) after video-assisted thoracoscopic surgery lobectomies, 5 (11.4%) after sleeve lobectomies, and 4 (9%) after pneumonectomies. Causes of death included 24 (54.5%) respiratory failure, 10 (22.7%) ischemic bowel, 4 (9%) coronary events, 2 (4.5%) strokes, 2 (4.5%) on table hemorrhage, 1 (2.3%) massive pulmonary embolus, and 1 (2.3%) postoperative hemorrhage. CONCLUSION: Although respiratory failure is still a major cause of mortality in the postoperative patient, bowel ischemia has been found to be the second greatest cause of death. This study highlights the need to identify those at risk of this fatal complication during preoperative assessment and their postoperative management.